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Songvut P, Boonyarattanasoonthorn T, Nuengchamnong N, Junsai T, Kongratanapasert T, Supannapan K, Khemawoot P. Enhancing oral bioavailability of andrographolide using solubilizing agents and bioenhancer: comparative pharmacokinetics of Andrographis paniculata formulations in beagle dogs. PHARMACEUTICAL BIOLOGY 2024; 62:183-194. [PMID: 38351624 PMCID: PMC10868414 DOI: 10.1080/13880209.2024.2311201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Accepted: 01/23/2024] [Indexed: 02/16/2024]
Abstract
CONTEXT The therapeutic potential of andrographolide is hindered by its poor oral bioavailability and unpredictable pharmacokinetics, primarily due to its limited water solubility. OBJECTIVE This work aimed to enhance the solubility and pharmacokinetics of andrographolide, a bioactive compound in Andrographis paniculata (Burm. f.) Nees (Acanthaceae), using solubilizing agents and a bioenhancer. MATERIALS AND METHODS Four groups of beagles were compared: (1) A. paniculata powder alone (control), (2) A. paniculata powder with 50% weight/weight (w/w) β-cyclodextrin solubilizer, (3) A. paniculata powder with 1% w/w sodium dodecyl sulfate (SDS) solubilizer, and (4) A. paniculata powder co-administered with 1% w/w SDS solubilizer and 10% piperine bioenhancer. All groups received a consistent oral dose of 3 mg/kg of andrographolide, administered both as a single dose and multiple doses over seven consecutive days. RESULTS Thirteen chemical compounds were identified in A. paniculata powder, including 7 diterpenoids, 5 flavonoids, and 1 phenolic compound. A. paniculata co-administration with either 50% w/w β-cyclodextrin or 1% w/w SDS, alone or in combination with 10% w/w piperine, significantly increased systemic andrographolide exposure by enhancing bioavailability (131.01% to 196.05%) following single and multiple oral co-administration. Glucuronidation is one possible biotransformation pathway for andrographolide, as evidenced by the excretion of glucuronide conjugates in urine and feces. CONCLUSION The combination of solubilizing agents and a bioenhancer improved the oral bioavailability and pharmacokinetics of andrographolide, indicating potential implications for A. paniculata formulations and clinical therapeutic benefits. Further investigation in clinical studies is warranted.
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Affiliation(s)
- Phanit Songvut
- Laboratory of Pharmacology, Chulabhorn Research Institute, Bangkok, Thailand
| | | | - Nitra Nuengchamnong
- Science Laboratory Center, Faculty of Science, Naresuan University, Phitsanulok, Thailand
| | - Thammaporn Junsai
- Chakri Naruebodindra Medical Institute, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Samutprakarn, Thailand
| | - Teetat Kongratanapasert
- Chakri Naruebodindra Medical Institute, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Samutprakarn, Thailand
| | | | - Phisit Khemawoot
- Chakri Naruebodindra Medical Institute, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Samutprakarn, Thailand
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Maikhunthod B, Chaipayang S, Jittmittraphap A, Thippornchai N, Boonchuen P, Tittabutr P, Eumkeb G, Sabuakham S, Rungrotmongkol T, Mahalapbutr P, Leaungwutiwong P, Teaumroong N, Tanthanuch W. Exploring the therapeutic potential of Thai medicinal plants: in vitro screening and in silico docking of phytoconstituents for novel anti-SARS-CoV-2 agents. BMC Complement Med Ther 2024; 24:274. [PMID: 39030504 PMCID: PMC11264683 DOI: 10.1186/s12906-024-04586-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2023] [Accepted: 07/10/2024] [Indexed: 07/21/2024] Open
Abstract
BACKGROUND The high virulence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), responsible for coronavirus disease 2019 (COVID-19), has triggered global health and economic concerns. The absence of specific antiviral treatments and the side effects of repurposed drugs present persistent challenges. This study explored a promising antiviral herbal extract against SARS-CoV-2 from selected Thai medicinal plants based on in vitro efficacy and evaluated its antiviral lead compounds by molecular docking. METHODS Twenty-two different ethanolic-aqueous crude extracts (CEs) were rapidly screened for their potential activity against porcine epidemic diarrhea virus (PEDV) as a surrogate using a plaque reduction assay. Extracts achieving ≥ 70% anti-PEDV efficacy proceeded to the anti-SARS-CoV-2 activity test using a 50% tissue culture infectious dose method in Vero E6 cells. Molnupiravir and extract-free media served as positive and negative controls, respectively. Potent CEs underwent water/ethyl acetate fractionation to enhance antiviral efficacy, and the fractions were tested for anti-SARS-CoV-2 performance. The fraction with the highest antiviral potency was identified using liquid chromatography-high-resolution mass spectrometry (LC-HRMS). Molecular docking analyses of these compounds against the main protease (Mpro) of SARS-CoV-2 (6LU7) were performed to identify antiviral lead molecules. The top three hits were further evaluated for their conformational stability in the docked complex using molecular dynamics (MD) simulation. RESULTS The water fraction of mulberry (Morus alba Linn.) leaf CE (WF-MLCE) exhibited the most potent anti-SARS-CoV-2 efficacy with low cytotoxicity profile (CC50 of ~ 0.7 mg/mL), achieving 99.92% in pre-entry mode and 99.88% in postinfection treatment mode at 0.25 mg/mL. Flavonoids and conjugates were the predominant compounds identified in WF-MLCE. Molecular docking scores of several flavonoids against SARS-CoV-2 Mpro demonstrated their superior antiviral potency compared to molnupiravir. Remarkably, myricetin-3-O-β-D-galactopyranoside, maragrol B, and quercetin 3-O-robinobioside exhibited binding energies of ~ - 9 kcal/mol. The stability of each ligand-protein complex of these compounds with the Mpro system showed stability during MD simulation. These three molecules were pronounced as antiviral leads of WF-MLCE. Given the low cytotoxicity and high antiviral potency of WF-MLCE, it holds promise as a candidate for future therapeutic development for COVID-19 treatment, especially considering its economic and pharmacological advantages.
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Affiliation(s)
- Bussayarat Maikhunthod
- School of Biotechnology, Institute of Agricultural Technology, Suranaree University of Technology, Nakhon Ratchasima, 30000, Thailand
| | - Sukanya Chaipayang
- Synchrotron Light Research Institute (Public Organization), Nakhon Ratchasima, 30000, Thailand
| | - Akanitt Jittmittraphap
- Department of Microbiology and Immunology, Faculty of Tropical Medicine, Mahidol University, Bangkok, 10400, Thailand
| | - Narin Thippornchai
- Department of Microbiology and Immunology, Faculty of Tropical Medicine, Mahidol University, Bangkok, 10400, Thailand
| | - Pakpoom Boonchuen
- School of Biotechnology, Institute of Agricultural Technology, Suranaree University of Technology, Nakhon Ratchasima, 30000, Thailand
| | - Panlada Tittabutr
- School of Biotechnology, Institute of Agricultural Technology, Suranaree University of Technology, Nakhon Ratchasima, 30000, Thailand
| | - Griangsak Eumkeb
- School of Preclinical Sciences, Institute of Science, Suranaree University of Technology, Nakhon Ratchasima, 30000, Thailand
| | - Sahachai Sabuakham
- Department of Biochemistry, Center for Translational Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen, 40002, Thailand
| | - Thanyada Rungrotmongkol
- Program in Bioinformatics and Computational Biology, Graduate School, Chulalongkorn University, Bangkok, 10330, Thailand
- Center of Excellence in Structural and Computational Biology, Department of Biochemistry, Faculty of Science, Chulalongkorn University, Bangkok, 10330, Thailand
| | - Panupong Mahalapbutr
- Department of Biochemistry, Center for Translational Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen, 40002, Thailand
| | - Pornsawan Leaungwutiwong
- Department of Microbiology and Immunology, Faculty of Tropical Medicine, Mahidol University, Bangkok, 10400, Thailand
| | - Neung Teaumroong
- School of Biotechnology, Institute of Agricultural Technology, Suranaree University of Technology, Nakhon Ratchasima, 30000, Thailand.
| | - Waraporn Tanthanuch
- Synchrotron Light Research Institute (Public Organization), Nakhon Ratchasima, 30000, Thailand.
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Barbosa H, Espinoza GZ, Amaral M, de Castro Levatti EV, Abiuzi MB, Veríssimo GC, Fernandes PDO, Maltarollo VG, Tempone AG, Honorio KM, Lago JHG. Andrographolide: A Diterpenoid from Cymbopogon schoenanthus Identified as a New Hit Compound against Trypanosoma cruzi Using Machine Learning and Experimental Approaches. J Chem Inf Model 2024; 64:2565-2576. [PMID: 38148604 DOI: 10.1021/acs.jcim.3c01410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2023]
Abstract
American Trypanosomiasis, also known as Chagas disease, is caused by the protozoan Trypanosoma cruzi and exhibits limited options for treatment. Natural products offer various structurally complex metabolites with biological activities, including those with anti-T. cruzi potential. The discovery and development of prototypes based on natural products frequently display multiple phases that could be facilitated by machine learning techniques to provide a fast and efficient method for selecting new hit candidates. Using Random Forest and k-Nearest Neighbors, two models were constructed to predict the biological activity of natural products from plants against intracellular amastigotes of T. cruzi. The diterpenoid andrographolide was identified from a virtual screening as a promising hit compound. Hereafter, it was isolated from Cymbopogon schoenanthus and chemically characterized by spectral data analysis. Andrographolide was evaluated against trypomastigote and amastigote forms of T. cruzi, showing IC50 values of 29.4 and 2.9 μM, respectively, while the standard drug benznidazole displayed IC50 values of 17.7 and 5.0 μM, respectively. Additionally, the isolated compound exhibited a reduced cytotoxicity (CC50 = 92.8 μM) against mammalian cells and afforded a selectivity index (SI) of 32, similar to that of benznidazole (SI = 39). From the in silico analyses, we can conclude that andrographolide fulfills many requirements implemented by DNDi to be a hit compound. Therefore, this work successfully obtained machine learning models capable of predicting the activity of compounds against intracellular forms of T. cruzi.
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Affiliation(s)
- Henrique Barbosa
- Center for Natural and Human Sciences, Federal University of ABC, São Paulo 09210-180, Brazil
| | | | - Maiara Amaral
- Laboratory of Pathophysiology, Butantan Institute, São Paulo 05503-900, Brazil
| | | | | | - Gabriel Correa Veríssimo
- Department of Pharmaceutical Products, Federal University of Minas Gerais, Minas Gerais, 31270-901, Brazil
| | | | | | | | - Kathia Maria Honorio
- Center for Natural and Human Sciences, Federal University of ABC, São Paulo 09210-180, Brazil
- School of Arts, Science, and Humanities, University of São Paulo, São Paulo 03828-000, Brazil
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Jia L, Beidelschies M, Evans JM, Niemtzow RC, Niemtzow SZ, Dusek JA, Lin Y, Wu C, Su YC, Wang CJ, Lin CY, Astana PRW, Ardiyanto D, Hardjoutomo R, Visithanon K, Puagkong J, Chokpaisarn J, Lopez MV, Yotsuyanagi H, Lee MS, Ramirez HJG, Bobadilla CP, Quinteros EMG, Galanti de la Paz M, Maramba-Lazarte CC. Recommendations and guidelines of integrative medicine for COVID-19 care: The APEC project outcome. Integr Med Res 2024; 13:101022. [PMID: 38434793 PMCID: PMC10907161 DOI: 10.1016/j.imr.2024.101022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Accepted: 02/05/2024] [Indexed: 03/05/2024] Open
Abstract
This article - Recommendations and Guidelines of Integrative Medicine (IM) for COVID-19 Care - was one of the outcomes from an Asia-Pacific Economic Cooperation (APEC) Project (Integrative Medicine (IM) and COVID -19 Care) during the time between May 2022 and March 2023. With the efforts from care providers, researchers, health policy makers and healthcare administrative leaders among APEC economies, the purpose of this file was to provide comprehensive IM systems for COVID-19 care as recommendations and suggestive guidelines including care methods, tools, procedures, symptom conditions and targets selections, and points need to be considered during care applications. All cited COVID-19 care practices have confirmed their efficacy and usefulness either used alone or combined with conventional medicine. This article provides current useful medical information on IM for COVID-19 care which could benefit APEC economies and world health communities on their healthcare system.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - C. Jason Wang
- National Research Institute of Chinese Medicine, Chinese Taipei
| | - Chien-Yu Lin
- Hsinchu MacKay Memorial Hospital, Chinese Taipei
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - APEC Health Working Group
- National Cancer Institute, USA
- Cleveland Clinic, USA
- The Center for Functional Medicine, USA
- The US Air Force Medical Corps, USA
- Connor Whole Health, USA
- Food and Drug Administration, USA
- Stanford University, USA
- National Research Institute of Chinese Medicine, Chinese Taipei
- Hsinchu MacKay Memorial Hospital, Chinese Taipei
- Sebelas Maret University of Surakarta, Indonesia
- Ministry of Health, Indonesia
- Public Health Management, Ministry of Health, Indonesia
- Department of Thai Traditional and Alternative Medicine, Thailand
- Prince of Songkla University, Thailand
- National University of San Marcos, Peru
- University of Tokyo, Japan
- Korea Institute of Oriental Medicine, Republic of Korea
- Complementary Care System, Mexico
- Academic Network of Integrative Medicine and Health, Chile
- Ministry of Health, Chile
- Academic University of Chile, Chile
- National Institutes of Health, Philippines
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Ratiani L, Pachkoria E, Mamageishvili N, Shengelia R, Hovhannisyan A, Panossian A. Efficacy of Kan Jang ® in Patients with Mild COVID-19: A Randomized, Quadruple-Blind, Placebo-Controlled Trial. Pharmaceuticals (Basel) 2023; 16:1196. [PMID: 37765004 PMCID: PMC10535596 DOI: 10.3390/ph16091196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2023] [Revised: 08/14/2023] [Accepted: 08/16/2023] [Indexed: 09/29/2023] Open
Abstract
Background and aim. This study aimed to assess the efficacy of the treatment of Kan Jang®, a fixed combination of Andrographis paniculata (Burm. F.) Wall. ex. Nees and Eleutherococcus senticosus (Rupr. & Maxim.) Maxim extracts in patients with mild symptoms of COVID-19. Methods. One hundred and forty patients received six capsules of Kan Jang® (n = 68, daily dose of andrographolides-90 mg) or placebo (n = 72) and supportive treatment (paracetamol) for 14 consecutive days in a randomized, quadruple-blinded, placebo-controlled, two-parallel-group design. The efficacy outcomes were the rate of cases turning to severe, the detection rate of coronavirus SARS-CoV-2 over the time of treatment, the duration, and the severity of symptoms (sore throat, runny nose, cough, headache, fatigue, loss of smell, taste, pain in muscles) in the acute phase of the disease. Other efficacy measures included improving cognitive and physical performance, quality of life, and the levels of inflammatory blood markers-interleukin 6 (IL-6), C-reactive protein, and D-dimer. Results. Kan Jang® significantly (p < 0.05) reduced the rate of cases turning to severe (5.36%) compared to the placebo (17.86%) and decreased the detection rate of SARS-CoV-2 virus over the time of the treatment. The statistical difference in the rates of patients with clinical deterioration in the Kan Jang treatment and placebo control groups was significant (p = 0.0176) both in the 112 patients in the included-per-protocol (IPP) analysis and in the 140 patients in the intended-to-treat (ITT) analysis (p = 0.0236); the absolute risk reduction in cases thanks to the Kan Jang treatment was 12.5%, and the number we needed to treat with Kan Jang was 8. The patient's recovery time (number of sick days at the home/clinic) was shorter in the Kan Jang group compared with the placebo group. The rate of attenuation of inflammatory symptoms in the Kan Jang® group was significantly higher, decreasing the severity of cough, sore throat/pain, runny nose, and muscle soreness compared with the placebo group. Kan Jang® significantly decreased the Wisconsin Upper Respiratory Symptoms scores compared to the placebo in the sample size of 140 patients. However, the relief of fatigue and headache and the decrease in IL-6 in the blood were observed only in a subset of 86 patients infected during the second three waves of the pandemic. Kan Jang® significantly increased physical activity and workout; however, it did not affect cognitive functions (attention and memory), quality of life score, inflammatory marker D-dimer, and C-reactive protein compared with the placebo group. Conclusions. Overall, the results of this study suggest that Kan Jang® is effective in treating mild and moderate COVID-19 irrespective of the SARS-CoV-2 variant of infection.
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Affiliation(s)
- Levan Ratiani
- Department of Infectious Diseases, The First University Clinic, Tbilisi State Medical University, Gudamakari St., Tbilisi 0141, Georgia; (L.R.); (E.P.)
| | - Elene Pachkoria
- Department of Infectious Diseases, The First University Clinic, Tbilisi State Medical University, Gudamakari St., Tbilisi 0141, Georgia; (L.R.); (E.P.)
| | - Nato Mamageishvili
- Department for History of Medicine and Bioethics, Faculty of Medicine, Tbilisi State Medical University, Vazha-Pshavela Ave. 33, Tbilisi 0162, Georgia; (N.M.); (R.S.)
| | - Ramaz Shengelia
- Department for History of Medicine and Bioethics, Faculty of Medicine, Tbilisi State Medical University, Vazha-Pshavela Ave. 33, Tbilisi 0162, Georgia; (N.M.); (R.S.)
| | - Areg Hovhannisyan
- Institute of Fine Organic Chemistry of the National Academy of Science, Azatutian Ave. 26, Yerevan 375014, Armenia;
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Halma MTJ, Plothe C, Marik P, Lawrie TA. Strategies for the Management of Spike Protein-Related Pathology. Microorganisms 2023; 11:1308. [PMID: 37317282 PMCID: PMC10222799 DOI: 10.3390/microorganisms11051308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Revised: 05/04/2023] [Accepted: 05/10/2023] [Indexed: 06/16/2023] Open
Abstract
In the wake of the COVID-19 crisis, a need has arisen to prevent and treat two related conditions, COVID-19 vaccine injury and long COVID-19, both of which can trace at least part of their aetiology to the spike protein, which can cause harm through several mechanisms. One significant mechanism of harm is vascular, and it is mediated by the spike protein, a common element of the COVID-19 illness, and it is related to receiving a COVID-19 vaccine. Given the significant number of people experiencing these two related conditions, it is imperative to develop treatment protocols, as well as to consider the diversity of people experiencing long COVID-19 and vaccine injury. This review summarizes the known treatment options for long COVID-19 and vaccine injury, their mechanisms, and their evidentiary basis.
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Affiliation(s)
| | - Christof Plothe
- Center for Biophysical Osteopathy, Am Wegweiser 27, 55232 Alzey, Germany
| | - Paul Marik
- Front Line COVID-19 Critical Care Alliance (FLCCC), 2001 L St. NW Suite 500, Washington, DC 20036, USA;
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Sheng X, Chen C, Jiang G, Ji Z, Guo Z, Hu H, Wang H, Zhai J, Zhang D, Zhang J, Guo L. The add-on effect of Shufeng Jiedu capsule for treating COVID-19: A systematic review and meta-analysis. Front Med (Lausanne) 2022; 9:1020286. [PMID: 36325392 PMCID: PMC9620801 DOI: 10.3389/fmed.2022.1020286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Accepted: 09/20/2022] [Indexed: 11/13/2022] Open
Abstract
Introduction Shufeng Jiedu capsule (SFJD) is a commonly used Chinese patent medicine in China. Some studies have reported that SFJD has therapeutic effects in patients diagnosed with COVID-19. This systematic review aimed to critically evaluate the efficacy and safety of SFJD combined with western medicine (WM) for treating COVID-19. Methods A literature search by using WHO COVID-19 database, PubMed, Embase, Cochrane Library, the Web of Science, CKNI, Wanfang, VIP, SinoMed, and clinical trial registries was conducted, up to 1 August 2022. Randomized controlled trials (RCTs), non-RCTs, cohort studies and case series of SFJD combined with WM for COVID-19 were included. Literature screening, data extraction, and quality assessment were performed independently by two reviewers in line with the same criteria. We used the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) to assess the certainty of evidence. Meta-analyses were performed with Revman 5.3 if possible. The descriptive analysis was conducted when the studies could not be meta-analyzed. Results Totally 10 studies with 1,083 patients were included. Their methodological quality were moderate. The results demonstrated that compared to WM group, SFJD + WM group remarkably increased the nucleic acid negative conversion rate (RR = 1.40, 95%CI: 1.07-1.84), total effective rate (RR = 1.18, 95%CI: 1.07-1.31), cure rate (RR = 4.06, 95%CI: 2.19-7.53), and the chest CT improvement rate (RR = 1.19, 95%CI: 1.08-1.31), shorten nucleic acid negative conversion time (MD = -0.70, 95%CI: -1.14 to -0.26), reduced the clinical symptom disappearance time (fever, diarrhea, cough, fatigue, pharyngalgia, nasal congestion, and rhinorrhea), as well as improved the levels of laboratory outcomes (CRP, IL-6, Lym, and Neu). Additionally, the incidence of adverse reactions did not exhibit any statistically significant difference between SFJD + WM group and WM group. Conclusion SFJD combined with WM seems more effective than WM alone for the treatment of COVID-19. However, more well-designed RCTs still are warranted. Systematic review registration [https://www.crd.york.ac.uk/PROSPERO/], identifier [CRD42022306307].
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Affiliation(s)
- Xiaodi Sheng
- Evidence-Based Medicine Center, Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Chao Chen
- First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Guowang Jiang
- Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Zhaochen Ji
- Evidence-Based Medicine Center, Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Zehui Guo
- Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Haiyin Hu
- Evidence-Based Medicine Center, Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Hui Wang
- Evidence-Based Medicine Center, Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Jingbo Zhai
- Evidence-Based Medicine Center, Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Dong Zhang
- Evidence-Based Medicine Center, Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Junhua Zhang
- Evidence-Based Medicine Center, Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Liping Guo
- Tianjin Academy of Traditional Chinese Medicine Affiliated Hospital, Tianjin, China,*Correspondence: Liping Guo,
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